South West Urological Association Meeting held at Southmead Hospital , Bristol , 30 th September 1983 RENAL TRANSPLANTATION

Recent advances have proved advantageous in paediatrics and renal transplantation. Continuous Ambulatory Peritoneal Dialysis (CAPD) facilitates dialysis of low weight children including babies. The beneficial effects of pretransplant blood transfusions are appreciated, likewise donor specific blood transfusions in the case of living donors. DR typing has a stronger correlation with graft success than conventional tissue typing. The use of lower doses of steroids reduces the side effects and

Ambulatory Peritoneal Dialysis (CAPD) facilitates dialysis of low weight children including babies. The beneficial effects of pretransplant blood transfusions are appreciated, likewise donor specific blood transfusions in the case of living donors. DR typing has a stronger correlation with graft success than conventional tissue typing. The use of lower doses of steroids reduces the side effects and growth retardation in children. The new immunosuppression agent Cyclosporin A may prove beneficial.
Examples of successful paediatric kidney transplants at Southmead illustrating these features were presented ranging upwards in age from 6 years. The causes of renal failure varied from congenital 'reflux nephropathy' to Henoch-Schonlein's purpura.
Two failures were described. A girl of 12 received a transplant that was initially very successful, only to suffer a recurrence of her original disease (mesangiocapillary glomerulo-nephritis Type II) in the graft. A 7-kg baby transplanted with some reservations lost its graft from a ureteric leak. The transplanted kidney of a 14-year-old boy, however, was saved by the use of a Boari flap after it had sloughed its entire ureter. Two girls aged 7 and 12 who had 'occult neurogenic' bladders managed by self-catheterisation received successful transplants into their bladders with no undue problems of infection.
A girl whose ureters were diverted at the age of 10 months for 'mega ureter, mega cystitis' received a transplant draining into her bladder more than 16 years later. There were no problems of micturition. The use of Teflon in the treatment of urinary incontinence was first described by Berg (1973) and then by Politano (1974). The injection of the viscous paste into the urethra and periurethral tissues aims to increase the urethral resistance in patients whose urinary incontinence is related to a reduced urethral pressure. This method has been used particularly in those women whose initial operative treatment had failed to control the urinary leakage. Detailed assessment, including urodynamic studies, is essential to select those patients suitable for this approach. The injection of the Polytef paste (Ethicon) is given at the time of cystoscopy under general an-aesthesia. Following examination of the bladder, a 0 degree telescope is used to visualise the bladder neck and proximal urethra. A 1.7 mm intravenous medicut Argyle needle with cannula is introduced between the external urethral meatus and vagina and advanced between these structures to the level of the bladder neck. The needle is removed and a 5 ml syringe filled with the paste is attached to the cannula. Injection requires strong pressure and the aim is to create a bulge on the posterior aspect of the bladder neck. Care is needed to avoid penetration or undue pallor of the mucosa during the injection. Further injections are then given at the lateral aspects of the bladder neck on either side, thus producing the final appearance similar to that of middle and lateral lobe enlargement of the prostate gland. A total of 15-20 ml of Polytef is used.
The results of an initial series of patients were outlined by Lim et al. in 1983. Twenty-eight female patients were treated by this method, of whom 26 had previously undergone operative treatment for urinary incontinence. Six patients were cured of their incontinence following the injection and 9 were temporarily improved. Thirteen patients experienced no change. If patients with detrusor instability had been excluded from this series, the results would have been improved.
The use of Teflon paste in the treatment of women with urinary incontinence is a simple procedure. The duration of stay in hospital is short and usually less than 4 days. If the initial treatment is not successful, a repeat injection can be given. The Polytef paste causes a foreign body giant cell reaction at the site of the injection. The best results were achieved in those patients who showed a high cystometric capacity and a low maximum urethral pressure on urodynamic investigation. Many urologists are regularly faced with the problem of the female with recurrent frequency and dysuria in whom 'conservative' treatment, including numerous courses of antibiotics, has failed. This procedure has been used to treat a small number of patients whose urinary symptomatology is unquestionably postcoital. The sound theoretical basis for this approach is precisely defined on anatomical grounds. A relative 'hypospadias' of the external urethral meatus results from persistent hymenal remnants tethering the urethra into an intravaginal position. A ventral hood is frequently present over the meatus, and the net effect of these abnormalities is to render the patient likely to develop the condition known as 'traumatic transvaginal cysto-urethritis' as a result of sexual activity. Such patients have urethral pain during intercourse (urethral dyspareunia), unexplained on grounds of bacterial contamination alone.
The minor procedure to release the urethra anteriorly, lessening its traumatisation during intercourse, is described. It is essential that no symptoms had occurred prior to the onset of sexual activity, abstinence from which characteristically produces The incidence of unsuspected or incidental carcinoma of the prostate found at transurethral resection for clinically benign obstructive disease is high and increases steadily with the age of the patient. Systematic sectioning of the prostate in men dying of another disease has shown that at least 30% of men over the age of 50 years have carcinoma of the prostate. There is a very large discrepancy, however, between those who have histological evidence of the disease and those who actually die from it. Is this due to latency or biological inactivity of the tumour or to a growth rate so slow that the condition usually does not present as a clinical problem? If one considers the often advanced age of the patient in whom incidental disease is diagnosed, then it can be appreciate that they are much more likely to die from another cause. The progress of 26 patients with incidental carcinoma of the prostate, age 61-89 years (mean 74 years) followed for 2-9 years (mean 3.9 years), in whom no initial specific anti-cancer treatment was undertaken was reported. There were 4 deaths from unrelated causes. There were 2 patients, 3 years after initial diagnosis, who because of local progression of the carcinoma causing symptoms required a further TUR with bilateral orchidectomy in one case and Stilboestrol in the other. Both are alive and well at 2 years and 6 years respectively. The overall results of treatment demonstrated successful control of the disease in 25 patients who are alive and well (range 0.5-5.7 years, mean 3.1 years).
Sixteen patients have died, however, due to prostatic carcinoma (range of 0.7-3.5 years, mean 1.3 years). Three patients were lost to follow-up. Twelve patients have been regularly reviewed after radiotherapy using the Franzen prostatic needle aspiration technique. However, when those patients whose death was not attributable to the operation were discounted, the mortality fell to 1.63%. Cryoprostatectomy is a satisfactory and safe method of dealing with prostatic hypertrophy in an elderly and infirm age group.

INTERSTITIAL IODINE 125 IN THE TREATMENT OF LOCALISED PROSTATIC CANCER
Patrick Smith, Royal Infirmary, Bristol Prostatic cancer is now the second commonest tumour in men in the United Kingdom. The incidence in the South West is the highest in the land. Treatments for this disease are many and varied and must be considered in each case in relation to the individual patients. However, there are a group of men in whom the disease is detected early and without any obvious metastases. These patients should have some form of attempted curative therapy. In the past this has consisted of external beam radiotherapy. Though the results of this in terms of cure and, more importantly, local tumour control are excellent, complications are significant. For this reason the Department of Urology at the Bristol Royal Infirmary, in conjuction with the Radiotherapy Centre, has developed a technique of interstitial iodine 125 therapy. This treatment produces a high dose of local radiotherapy over a 6-month period. The radioactivity is emitted by a small tantalum seed encasing a radioactive iodine source. The seeds are inserted through cannula using an open operative technique. This involves a retropubic dissection of the prostate together with mobilisation of the pelvic floor to enable the whole gland to be visualised. Technique does cause some bleeding but this has not proved a problem to date. In all 10 patients have been treated in this way. All are alive and well, with no evidence of